The Rawlin at Riverbend

Witness 1 (W1) and Alleged Victim (AV) have known impaired memory and reside at AP1 for their care needs and safety. W1 is known to react aggressively towards other residents and has been involved in multiple resident-to-resident altercations. An intervention for W1 dated on or about April 19, 2025, indicates W1 is not to have residents sit next to W1 in order to stop altercations. On or about May 4, 2025, staff noted W1 had been "in a mood that day " and received an as-needed medication for agitation. W1 and AV were seated on a couch together, engaged in an activity, when W1 tapped AV, AV tapped W1 back and then W1 began screaming and aggressively hitting AV. The facility failed to provide a safe environment for AV by failing to follow W1 interventions resulting in a resident-to-resident altercation, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness #1 (W1) is known to engage in altercations and there is an expectation of staff to supervise W1 while in the common area. On or about November 21, 2024, the Alleged Victim (AV) and W1 engaged in an altercation where W1 punched AV in the stomach, causing unreasonable discomfort. The facility's failure to provide a safe environment is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) lives at Facility (AP1) which manages all of AV's health and safety needs due to AV's impaired cognition. AV is impulsive and easily agitated. On or about November 9, 2024, AV took a bottle of cleaning product that was sitting on the kitchen counter and drank one gulp. Several staff tried to get the bottle away from AV, but AV would not let it go for some time. Staff called poison control and was told to monitor AV and push fluids. AV did not show any negative effects from drinking the cleaning product. Staff are trained on chemical safety during initial hiring on-boarding. Cleaning products are not supposed to be left out on the counter or under the kitchen sink; all cleaning products are to be stored in the hallway cleaning closet that is significantly far from the kitchen area. During a facility visit on or about November 19, 2024, staff were reminded over the walkie talkie by management to remove cleaning products from the kitchen area. After the walkie talkie announcement, cleaning products were seen on the kitchen counter and under the sink. The facility failed to provide a safe physical environment, failing to secure hazardous materials (e.g., cleaning solvents), which resulted in AV grabbing a bottle of cleaner from the counter and drinking it. Facility continued to have cleaning products not secured after this incident, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. AV’s service plan indicates medications will be set and administered according with the physician's medication/treatment orders. AV did not receive h/h diuretic medication as ordered from October 1, 2024, to October 6, 2024, which caused swelling in AV's legs and weight gain of nearly 5 lbs. The facility failed to provide a safe medication administration system to ensure AV's medications were available and administered as ordered. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Witness 1 (W1) has a history of wandering into other resident rooms including Alleged Victim's (AV's), which used to be W1's room. W1 has history of becoming upset at staff when redirected. On or about June 6, 2024, W1 was upset with staff due to staff not letting W1 go into AV's room, and attempted to hit staff due to being upset, requiring PRN Psychiatric medication to be given. On or about July 7, 2024, An altercation between W1 and AV took place when W1 entered AV room and W1 hit AV with W1's bag twice before leaving the room. On or about August 13, 2024, AV was receiving care from staff when W1 wandered into AV room and became upset. W1 swung W1's bag at staff and hit AV on the hand and finger unintentionally. The only instruction to staff in W1's service plan is to redirect W1 if W1 wanders. There is nothing in W1's care plan regarding W1's behaviors or agitation. A temporary service plan was put in place after this altercation to have staff redirect W1 from AV's room specifically. The facility failed to adjust the service plan and implement reasonable interventions to address W1 continued wandering into resident rooms, and aggressive behaviors, to protect the safety of other residents, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) is a known wanderer around the facility. Witness #1 (W1) is known to get into altercations with other residents. On or about June 22, 2024, AV wandered into W1's room, where they engaged in an altercation. Staff had been actively looking for AV when they found AV in W1's room. AV was found with a bloody nose and a swollen eye and cheek. The facility's failure to provide a safe environment and ensure adequate supervision of residents is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) has a diagnosis of Alzheimer's disease. Witness #1 (W1) has a diagnosis of unspecified dementia and a history of being the aggressor in altercations during peer-to-peer interactions. AV and W1 have a history of aggression with each other. AV resides in the room where W1 used to live, which causes W1 confusion. There is nothing in AV's or W1's service plan regarding behaviors or negative peer-to-peer interactions. AV and W1 have no instructions to staff about behaviors or escalation in preventative interventions. On or about May 24, 2024, AV and W1 were in a common area with other residents. W1 pulled on a blanket that AV was using, causing AV to pull the blanket back, resulting in AV falling onto the ground. AV obtained a skin tear from the altercation. W1 had five resident-to-resident altercations between March 4, 2024, to May 27, 2024. Neither AV's nor W1's care plan address resident-to-resident altercations, or the issue of these altercations occurring and escalating in frequency for W1. By not having any additional interventions, the facility failed to provide a safe environment and failed to properly plan care, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility failed to implement interventions and provide appropriate supervision according to the Alleged Victim’s (AV) and Witness 1's known behaviors and history of altercations. The failure resulted in an unwitnessed physical altercation, causing unreasonable discomfort and risk of further harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 30, 2023, AV and W1 had a physical altercation, resulting in AV being hit in the face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) have a history of resident-to-resident altercations. On or about November 26, 2023, AV and W1 had a physical altercation in W1’s room, resulting in AV having h/h middle finger closed in the door causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to the documentation, the facility failed to follow AV’S (Alleged Victim) service plan to provide supervision to prevent resident to resident altercations. The failure resulted in the facility staff leaving the AV alone in a common area while they were agitated without supervision and Witness 1 (W1) and AV got into a physical altercation resulting in the AV receiving a scratch to their face, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about September 3, 2023, AV and W1 had a physical altercation, resulting in AV sustaining an injury to h/h face causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The Alleged Victim (AV) relies on the facility to ensure a safe environment. Witness 1 (W1) has a history of resident-to-resident altercations. On or about June 11, 2023, AV and W1 had a physical altercation, resulting in AV sustaining an injury to h/h jaw causing pain and discomfort. The facility failed to ensure a safe environment for AV, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

On or about June 13, 2023, the facility failed to follow the Alleged Victim (AV) care planned for two-person transfers with toileting assistance. AV was assisted with one person while toileting instead of two, which resulted in AV falling suffering pain, and unreasonable discomfort. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

According to documentation the facility failed to follow The Alleged Victim (AV) care plan for assistance with changing AV’S briefs. The failure resulted in AV being found with soaked briefs experiencing a loss of dignity, and unreasonable discomfort. The facility failed to ensure care plans were followed, which is a violation of resident’s rights, is considered neglect of care and constitutes abuse. The allegation that the Alleged perpetrator 2 (AP2) failed to follow AV’S care plan was investigated and the determination was Inconclusive.

Alleged Victim (AV) relies on the facility for his/her care. On or about December 28, 2022, AV was yelling that he/she wanted to see their family member. Witness 1 (W1) come out of their room, told AV to shut up and said to AV, “nobody wants your family”, and then pushed AV to the ground. As a result, AV sustained red marks on their back and was crying and said that their back hurt. The facility failed to provide a homelike environment to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim’s (AV’s) Care Plan stated he/she is a high fall risk with an unsteady/shuffling gait. On or about December 15, 2022, AV sustained a fall which resulted in a shattered knee and right hip fracture. AV has a second fall on or about December 21, 2022. AV has a third fall on or about December 26, 2022, resulting in a hematoma with skin tear to the forehead and another skin tear to AV’s right arm. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) has significant cognitive impairment and is a fall risk, per his/her care plan. On or about December 15, 2022, AV was found on the floor in his/her room. As a result, AV sustained a skin tear below the right kneecap, some discoloration and swelling along with AV’s self-report of soreness and some pain. AV has sustained three (3) prior falls. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. AV had a prescription for Levetiraceta (Kepra) which begun on or about August 9, 2022. Between October 6th through 16th, 2022, AV was without any Levetiraceta (Kepra). Alleged Perpetrator 2 (AP2) did not correctly read the prescription and discontinued AV’s Kepra and there fore it was not given to AV. The facility and AP2 failed to provide a safe medication administration system for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is identified as having a cognitive impairment and is unable to judge risk of falls. Between February 8th through August 21, 222, AV sustained approximately eight (8) falls. Out of those falls, AV sustained injuries on four (4) of them such as a laceration to AV’s head, a contusion to AV’s back, wound to the back of AV’ s head and a contusion on AV’s left hip, and an abrasion to AV’s right side of the forehead and skin tear to the right elbow. On or about September 5, 2022, AV suffered a fall that resulted in a laceration to AV’s head. The facility failed to care plan appropriately and implement interventions to mitigate AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitute abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about August 24, 2022, a staff wheeled AV into the bathroom. AV was alone for a short amount of time before the staff member returned to find AV on the floor bleeding from his/her head. AV was transported to the hospital for care. AV had prior falls. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On two occasions Alleged Perpetrator 2 (AP2) had negative interactions with AV over the allowance of multiple packets of jam; staff know AV’s preferences and there is not a limit on what is given to residents. AP2 would not let AV have multiple packets or would require AV to recite “please and thank you” first. AV stated AP2 was rude with him/her. AP2 was employed at the facility for more than a year, and in that time, they received at least two disciplinary actions relating to their unacceptable behaviors. AP2 failed to provide a safe environment for AV, which is neglect of care and constitutes abuse. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about July 4, 2022, Alleged Perpetrator 2 (AP2) brough a family member to the facility, and this individual was running around the common areas. AV made a comment that AP2 should control his/her family member’s behavior and AP2 raised their voice at AV for speaking about his/her family member. AP2 was employed at the facility for more than a year, and in that time, they received at least two disciplinary actions relating to their unacceptable behaviors such as raising their voice at residents. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to protect AV from verbal abuse, which is a violation of resident rights, is neglect of care and constitutes abuse.

Witness 1 (W1) is care planned to be supervised while in the common area. Staff are to supervise him/her if he/she displays behaviors. On or about June 16, 2022, W1 entered AV’s room and tried to take AV’s belongings. AV tried to get W1 out of his/her room and W1 began to hit AV. The day before the incident, W1 was having behaviors and W1 was not being supervised when the incident with AV occurred. The facility failed to follow W1’s care plan, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) is care planned to be a two-person assist. On or about June 4, 2022, a staff member was helping AV change when AV stumbled backwards and fell. On June 5, 2022, AV was feeling pain and was given Tylenol, but the pain continued. The facility failed to follow the care plan around AV being a two-person assist, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. On or about May 29, 2022, AV, and Witness 1 (W1) were in a shared common area, and AV was knocked to the ground by W1, which caused an abrasion to AV’s elbow. The facility failed to provide a safe environment, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care needs. On or about May 16, 2022, while AV was sitting at a dinner table., witness 6 (W6) approached AV at the table, pulled out a shoe which he/she had tucked in his/her waistband, and hit AV on the head with the shoe. The facility failed to provide a safe environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility to administer his/her medications. A bottle of liquid Lorazepam was signed in on March 21, 2022. On or about May 10, 2022, it was discovered that a bottle of liquid Lorazepam was missing from the refrigerator where liquid medications are stored. The missing medication was not reported missing until May 12, 2022. Staff were not conducting visual checks of medications between shifts as stated in the Controlled Substance Management Policy. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV was a sliding scale insulin prior to being admitted to the facility. AV’s MD ordered sliding scale insulin on or about March 29, 2022. The facility agreed to provide assistance with medication and treatment requiring a registered nurse training and supervision, including blood sugar testing and insulin. However, the facility refused to provide sliding scale insulin for AV, resulting in AV’s diabetes being out of control; AV being sent to the hospitals on multiple occasions, his/her blood sugar was out of control, his/her A1C was high, and his/her weight was off. The facility failed to provide service to AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) fall history. On or about February 16, 2022, AV suffered a fall resulting in a bruise on h/h right hip. The failure resulted in AV experiencing pain and unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. During the month of November 2021, AV sustained two falls. No interventions were developed nor implemented by the facility after the November falls. On or about February 13, 2022, AV feel and incurred a fracture to his/her elbow. The facility failed to care plan around AV’s risk of falls, which is a violation of resident rights, is neglect of care and constitutes abuse.

Alleged Victim (AV) relies on the facility for his/her care. AV had five (5) falls in three months with no progressing changes in AV’s care plan. The facility did not update AV’ care plan in December 2021 and January 2022 regarding the falls. The facility received wound care instructions for AV, but AV was sent back to the ER due to infection of wound on January 13th and 15th, 2022. The facility was not providing wound care to AV. The facility failed to provide service, which is a violation of resident rights, is neglect of care and constitutes abuse.

On or about October 23, 2021, the Alleged Victim (AV) was found on the floor at approximately 7:40 am. AV was sent out to the hospital for treatment and was diagnosed with two broken toes and a broken nose. AV was care planned to be checked every two hours and at shift change. AV had not been seen by any staff since 2:00 am. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

The facility allegedly failed to coordinate with outside service providers regarding a medication for AV. A bottle of medication with AVs name had been stored in the medication cart while waiting for orders. There were no physician’s orders for the medication, no documentation in the AVs record of a visit to an outside provider, or any follow up the facility had taken to get the information from the provider. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

Based on interview and record review, the facility failed to update and document the ABST evaluation for each resident no less than quarterly. The facility’s failure is a violation of Oregon Administrative Rules.

Alleged Victim (AV) lives at Respondent’s facility. Around August 2025, facility staff reported Alleged Perpetrator #2(AP2) took pictures and videos of residents with AP2's personal phone. Including AV, AP2 took a picture of AV who was wearing only a brief. AP2's actions are a violation of resident rights, which is considered neglect of care and constitutes abuse. The facility failed to ensure the residents rights, which is a violation of Oregon Administrative rules.

Alleged Victim (AV) lived at Respondent’s facility. Alleged Perpetrator (AP2) has history of taking selfies and posting pictures on social media of residents. A video of AV having behaviors in the shower was taken by APS and shown to other staff members. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility failed to ensure AV's rights were protected, which is a violation or Oregon Administrative Rules.

On or about August 22, 2025, Alleged Perpetrator 2 (AP2) used a social media application to distribute a message containing an image of the Alleged Victim (AV) engaged in a private sexual act. This image was initially sent to multiple staff members associated with Alleged Perpetrator 1 (AP1), and subsequently AP2 also verbally disclosed AV actions to other staff members. The AV was unaware that an intimate image had been captured and distributed. It is reasonable to conclude that, if informed, the AV would experience emotional harm as a result of this disclosure. AP2’s actions constitute a serious violation of the resident’s rights, is neglect of care, and constitutes abuse. The facility failed to provide adequate oversight and monitoring of AP2 and failed to ensure the protection of resident rights, which is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffing to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

Alleged Victim (AV) is a resident of a locked memory care facility. AV experiences significant cognitive impairment and relies on AP1 to manage AV's daily care needs. AV does not have a history on wandering. On or about June 15, 2025, AV was found by staff standing next to the dumpsters outside of AP1 after lunch time. It was determined that the gate was not fully latched, and the gate alarms were turned off. AV was placed on alert, a TSP was implemented, and AV's family was notified. AV sustained no injury and was last seen five minutes prior to the elopement. The facility failed to provide a safe environment, which is a violation of Oregon Administrative Rules.

Based on observations, interview, and record review, conducted during a site visit on 06/25/25, the facility’s failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: At approximately 12:25 pm, the east gate was observed to be closed and locked on 06/25/25. The door alarm was working while the door was open. Signage was posted on the door to “ensure the gate is closed for our residents’ safety.” A review of Resident 1’s service plan updated on 04/02/25, progress notes dated 04/02/25 through 06/14/25, and incident report dated 06/15/25 indicated the following: Resident 1 was found outside the gates of the east courtyard on 06/15/25 near the dumpsters; Resident 1 was last seen five minutes prior to elopement and did not have any injuries or need medical care; and Resident 1 did not have a history of elopement or exit-seeking behaviors. In interviews with Staff 1 (Executive Director) and Staff 2 (Licensed Practical Nurse), they reported the gate hadn’t been closed correctly when someone had gone out earlier. The door alarm did not go off while the door was open, and staff had reported it had been turned off. The alarm was turned back on, maintenance was called, and the gate was checked and found to be in working order. Staff 1 stated they added another sign to make sure the gate was closed correctly. The facility’s failure to exercise reasonable precautions against any conditions that may threaten the health, safety, or welfare of residents was substantiated

Based on observation and interview, conducted during a site visit on 02/27/25, the facility’s failure to ensure locked storage for all poisons, chemicals, rodenticides, and other toxic materials was substantiated. Findings include, but are not limited to: Compliance Specialist (CS) observed a bottle labeled multi-purpose cleaner under the sink, in the kitchenette, in the Walnut neighborhood on 02/27/25. The gate to the kitchenette did not have a lock and was open. In an interview, Staff 2 (Caregiver) stated the door to the kitchenette didn’t lock, and chemicals were supposed to be kept in the locked storage next to the kitchen or in the storage down the hall. The facility’s failure to ensure locked storage for all poisons, chemicals, rodenticides, and other toxic materials was substantiated.

A review of Resident 1’s September 2024 MAR and progress notes, and physician orders indicated the following: Order effective 08/28/24 for Mirtazapine 15 MG tab (Remeron): Take 1 tablet by mouth nightly for mood; On 09/02/24, 09/15/24, and 09/16/24 Mirtazapine was documented in MAR as not given due to “med not available” or “wrong dosage in med cart”; Progress note dated 09/17/24 at 1:43pm by Staff 2, reported Mirtazapine dose was changed from 7.5 MG nightly to 15 MG nightly, however, on 09/15 and 09/16 resident did not get their med because staff thought they did not have it, when they did, and a couple of days between 8/28-9/16, resident was given 7.5 MG instead of 15 MG; Order effective 06/28/23 for Flutic/Salmet 232/14MCG Respi: Inhale 1 puff by mouth every 12 hours Rinse mouth and spit after use for Shortness of breath; On 09/03/24, Flutic/Salmet 232/14 MCG Respi was not administered due to “cannot find in med cart”. The findings were reviewed with and acknowledged by Staff 1 and Staff 2 on 10/02/24. It was confirmed the facility failed to carry out medication and treatment orders as prescribed.

Facility failure to cooperate with Department personnel in inspections, complaint investigations, planning for resident care, application procedures, and other necessary activities. An investigation determined this is a violation of Oregon Administrative Rules.

The facility failed to administer the resident's medication as order by their physician. An investigation determined this is a violation of Oregon Administrative Rules.

On or about May 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

On or about April 1, 2023, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing for a total of 30 days.

The facility failed to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse and promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the re-occurrence of abuse in accordance with OAR 411-054-0028(2)(b) and (3).

Alleged Victim (AV) relies on the facility for his/her care. Alleged Perpetrator 2 (AP2) was trained on appropriate verbal and emotional interactions with residents. On or about March 1, 2023, AP2 was observed screaming curse words, referring to AV as “retarded” and flipping off AV at the end of his/her shift following finding urine in a laundry basket. AP2 failed to protect AV from emotional abuse, which is a neglect of care and constitutes abuse. The facility failed to protect AV from emotional abuse, which is a violation of Oregon Administrative Rules.

The facility failed to include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation, which is a violation of Oregon Administrative Rules.

The facility failed to provide written policies, action or intervention for change of condition and monitoring for residents, provide written communicated to staff on each shift to ensure a resident monitoring and reporting system is implemented 24-hours a day, which is a violation of Oregon Administrative Rules

The facility failed to implement a system for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility, which is a violation of Oregon Administrative Rules.

The facility failed to carry out medication and treatment orders as prescribed, which is a violation of Oregon Administrative Rules.

Alleged Victim (AV) relies on the facility for his/her care. On or about October 18, 2022, Alleged Perpetrator 2 (AP2) was heard yelling at AV for needing help after AV peed his/her bed. AV stated thatAP2 had called her names and told him/her that he/she was stupid because AV had urinated on a towel or somewhere AV was not supposed to. AP2 failed to protect AV from verbal abuse, which is neglect of care and constitutes abuse. The facility failed to assure AV was protected from verbal abuse, which is a violation of Oregon Administrative Rules.

On or about October 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from September 1, 2022 to September 30, 2022, for a total of 30 days.

On or about September 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from August 1, 2022 to August 31, 2022, for a total of 30 days.